Site Registration Site Release Record Update

FOR OFFICE USE ONLY NORM SITE NOTIFICATION FORM GENERAL LICENSE # Subject to General Licensure DEPARTMENT OF ENVIRONMENTAL QUALITY NORM FACILITY ID# EMERGENCY & RADIOLOGICAL DIVISION LICENSING & REGISTRATIONS SECTION AI# POST OFFICE BOX 4312 BATON ROUGE, LOUISIANA 70821-4312 PHONE: (225) 219-3041 FAX: (225) 219-3154 Form RPD-36 (Rev 6/06) This form is for  Site Registration  Site Release  Record Update

NORM NOTIFIER INFORMATION

NORM General License Number: Agency Interest (AI) Number: Federal ID#: LA- ______-N01

Notifier Name:

Physical Address: No. & Street City & State Zip Code Parish

Mailing Address: No. & Street City & State Zip Code

Billing Address: No. & Street City & State Zip Code

Primary Contact: Job Title:

Telephone #: Fax#: ( ) ( )

NORM SITE INFORMATION

Type of Site (i.e. well site, production facility, pipe yard, drum storage, refinery, etc.):

Facility Name or Well Name: Well Serial # or Facility ID#:

Field Lease Name (if applicable): Field ID#:

Physical Location/Address:

Parish: Location Phone #: ( )

Directions to Site (origin point from nearest city limits):

Briefly Describe Site (size, terrain, structures):

Describe How This Site Became Subject to Norm Regulations/Type of Contamination:

Section Township Range Latitude Longitude ______° ______' ______" ______° ______' ______"

SURVEY INFORMATION

Survey Date: BACKGROUND READING (micro roentgens/hr):

Surveyor’s Name & Company Affiliation:

Radiation Instrument Used: Calibration Date:

Highest Exposure Reading Measured on a Piece of Equipment (micro Highest Exposure Reading Measured on the Ground/or Solids roentgens/hr): (microroentgens/hr):

Isotope Activity (picocuries per gram) TOTAL ACTIVITY Concentration:  Radium 226 (picocuries per gram)  Radium 228  Other NORM radionuclide(s) ______Approved/Accredited Laboratory Agency Interest Number of Laboratory

ADDITONAL INFORMATION REQUIRED FOR SITE RELEASE REQUESTS

1. Type of contamination, (i.e., soil, piping, heater treater, etc.)

2. Location of remediation or decontamination activities a. on site – copy(ies) of Form RPD-35 Temporary Jobsite Notification indicating the specific licensee(s) that performed the work b. off site – the specific licensee/facility and copy(ies) of Form RPD-37 NORM Waste Manifest indicating transfer

3. Copy of closeout survey, sample results (pCi/g for soil) performed after cleanup, and qualifications of person who performed survey

4. Contact person (with phone number) for facility to be released (person to accompany DEQ inspector out to the facility location) Contact person must be knowledgeable about facility NORM contamination and/or cleanup operations performed at facility

5. Records indicating the whereabouts and status of NORM waste and/or contaminated equipment transferred from the site including copy(ies) of Form RPD-37 NORM Waste Manifest to specifically licensed treatment, decontamination, storage, or disposal facilities

6. Results of tests, experiments, or any other analyses relating to backfill of excavated areas, closure and sealing

7. Any new information regarding the environmental impact of closure activities and long-term performance of the NORM site

**PLEASE NOTE** The Department does not consider a Plugged & Abandoned report as confirmation or verification that the previously reported NORM contamination has been removed.

WEB LINKS

Name Type Link RPD-34 REQUEST FOR DISPOSAL IN A WELL TO BE P & A http://www.deq.louisiana.gov/portal/tabid/240/Default.aspx RPD-35 TEMPORARY JOBSITE NOTIFICATION http://www.deq.louisiana.gov/portal/tabid/240/Default.aspx RPD-36 NOTIFICATION OF A NORM SITE http://www.deq.louisiana.gov/portal/tabid/240/Default.aspx RPD-37 NORM WASTE MANIFEST http://www.deq.louisiana.gov/portal/tabid/240/Default.aspx DRC-3 NOTICE TO EMPLOYEES-RADIATION NOTICE http://www.deq.louisiana.gov/portal/tabid/240/Default.aspx LAC 33:XV RADIATION PROTECTION REGULATIONS http://www.deq.louisiana.gov/portal/Default.aspx?tabid=1674

CERTIFICATION

Signature (Responsible Party/Company Representative) Notification Date

Name (Print) Job Title